N.J. Admin. Code § 10:56-2.14 - Oral and maxillofacial surgical services

(a) Dental extraction services shall be provided as follows:

1. Extraction of teeth other than those classified as non-restorable shall require prior authorization.

i. If a provider is considering any extraction which will necessitate the insertion of a dental prosthesis, the provider shall request prior authorization. Reimbursement for such an extraction rendered without prior authorization will be denied, or if already paid, reimbursement will be recovered. Due to the rule limiting the authorization of dentures, N.J.A.C. 10:56-2.13, it may be impossible to replace a denture following such extraction(s). Therefore, careful consideration should be given to the condition of teeth prior to a request for dentures initially; and prior to any extraction which would jeopardize an existing denture.

ii. When any extraction is to be performed in conjunction with or during orthodontic treatment, the dentist shall determine:

(1) That such orthodontic treatment has met the Salzmann Handicapping Malocclusion Guidelines established by the New Jersey Medicaid/NJ FamilyCare Program or has been prior authorized by a Division dental consultant.

(2) That such extraction has the express consent of the practitioner to whom orthodontic treatment has been authorized. Reimbursement will be denied (or if already paid, reimbursement will be recovered) for any extraction performed:

(A) In conjunction with orthodontic care, if such orthodontic treatment has not met the New Jersey Medicaid/NJ FamilyCare guidelines or has not been prior authorized by the Division dental consultant; or

(B) On a prior authorized orthodontic case without the consent of the practitioner to whom orthodontic treatment has been authorized, or without the approval of the Division dental consultant.

2. Reimbursement for dental extraction(s) includes local anesthesia, required suturing and routine post-operative care, including removal of the sutures. Alveoloplasty is reimbursable in conjunction with the extraction of teeth or the roots of teeth in the same quadrant during the same treatment visit. The alveoloplasty and the extractions shall be submitted on the same Dental Claim Form (MC-10) and have the same date of service.

3. Alveoloplasty, not related to current dental extraction(s), is reimbursable based on demonstrated dental necessity. Prior authorization shall not be required.

(b) Prior authorization shall not be required for the extraction of impacted teeth for beneficiaries age 18 and older. Prior authorization shall be required for such an extraction for beneficiaries under the age of 18. Extraction of impacted teeth should be undertaken only when conditions arising from such impactions warrant their removal. The extraction of asymptomatic impacted teeth or those teeth where dental/medical necessity cannot be demonstrated will not be accepted for reimbursement and shall be subject to recovery if payment has already been made.

1. In order to qualify for surgical removal of a tooth with partial or complete bony impaction, the following shall be required:

i. Incision of overlying soft tissue;

ii. Removal of bone; and/or

iii. Sectioning of the tooth.

(c) Other oral and maxillofacial surgery services shall be provided as follows:

1. Requests for prior authorization of oral surgical procedures, when such authorization is necessary, shall include a detailed description giving dates, diagnosis, site, and size of the operative area (number of lesions, and/or number and size of lacerations). For prior authorization, preoperative and any radiographs taken postoperatively, radiological, operative, and laboratory reports should be submitted directly to the Division dental consultant with the Dental Claim Form (MC-10). The dentist shall also make available all other reports, including hospital radiographs, upon request.

2. In the event that the oral surgery service to be performed is of an emergency nature and prior authorization is normally required but not feasible, then the Dental Prior Authorization Form (MC-10A) and the Dental Claim Form (MC-10) with all necessary information as mentioned in paragraph (c)1 above should be forwarded to the Division dental consultant for authorization prior to submission for payment.

3. The dentist performing a biopsy will receive reimbursement for the surgical portion only.

i. The laboratory performing the diagnostic service (and not the dentist) shall bill the program directly for the diagnostic service.

ii. The dentist will be reimbursed when the biopsy is performed as an independent procedure separate and apart, and on a different date from, the excision of the total lesion.

(d) Extractions to be performed for orthodontic purposes only shall be submitted to the Division dental consultant for prior authorization. Referrals for prior authorization shall be noted in section 14 of the Dental Claim Form, MC-10.

Notes

N.J. Admin. Code § 10:56-2.14

Amended by R.1986 d.385, effective 9/22/1986.
See: 18 N.J.R. 1337(a), 18 N.J.R. 1958(a).
Substantially amended.
Recodified from N.J.A.C. 10:56-1.20 and amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (b), substituted "beneficiaries" for "recipients"; added (d).
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
In (a), inserted references to NJ FamilyCare throughout.
Amended by R.2007 d.36, effective 2/5/2007.
See: 38 N.J.R. 3419(a), 39 N.J.R. 479(a).
Section was "Exodontia and oral surgery". Rewrote (a); in the introductory paragraph of (b), inserted new second sentence and "and shall be subject to recovery if payment has already been made"; deleted (b)2; rewrote (c); and in (d), inserted "dental consultant" and substituted "Dental Claim Form," for "Medicaid/NJ Family Care Dental Services Claim form".